Please complete the short questionnaire below before your first visit. All personal data will become part of your file once completed and submitted. This information is confidential and is for the clinic’s use only.

On your first visit, you will be asked to show your ID card and a referral form from your general physician or other doctor.

New patient questionnaire
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Name

Family history

Do/did any of your relatives suffer from the following diseases or disorders?

Personal history

List only serious illnesses, e.g. scarlet fever, rheumatic fever, tick-borne encephalitis, hospital stays, major injuries, etc.
What surgeries have you had? Provide the year of surgery and, if possible, the hospital you stayed at.
Gender

General

Allergies
Smoking
Alcohol
Black coffee
Soft drugs
Hard drugs
Have you received treatment for addiction?
(smoking, alcohol, drugs, gambling, etc.)
Chronic diseases
Hospital stays
Sports
Do you follow a diet?

Professional anamnesis and social history

Education
I live